MEDICARE: DR. J RUSSELL CORCORAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	MD06582	RI
2	208M00000X	Hospitalist Physician	MD06582	RI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	007056627	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689661241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J RUSSELL CORCORAN MD

Provider Business Mailing Address
First Line	:	100 KENYON AVE
Second Line	:
City	:	WAKEFIELD
State	:	RI
Zip	:	02879-4216
Country	:	US
Telephone Number	:	401-788-3929
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 KENYON AVE
Second Line	:	SUITE 215
City	:	WAKEFIELD
State	:	RI
Zip	:	02879-4239
Country	:	US
Telephone Number	:	401-783-0084
Fax Number	:	401-782-0005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	08/07/2015

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